PARTICIPANT
HANDOUT

Introduction

Researchers disagree as
to the exact number of lesbian, gay, bisexual, and transgendered (LGBT) individuals
living in the United States and other countries (Berger & Kelly, 1995).
Furthermore, considerable disagreement persists about the prevalence, causes,
and consequences of alcohol use and abuse among LGBT persons. Based on early
and methodologically unsound studies, reports of alarmingly high rates of alcohol
and other drug use within the LGBT population were published. More recent investigations
have revealed lower rates of heavy drinking and fewer differences in patterns
of use between LGBT and heterosexual groups.

Whether they drink more, the same,
or less than heterosexuals, LGBT persons are subject to many of the same risks
and consequences of use. In addition, they also encounter population-specific
risks. When addressing alcohol use/abuse prevention and treatment issues,
LGBT individuals deserve the same compassionate, informed responses as those
given to other populations or groups. The goal of this module is to increase
social workers' understanding of, and responsiveness to, the unique characteristics
and concerns of LGBT individuals in relation to alcohol use, prevention, and
treatment.

Learning Objectives

By the end of this module, learners
should be able to:

A. Become familiar with culturally
appropriate definitions of the terms lesbian, gay, bisexual, and transgendered,
used to identify members of the LGBT community
B. Identify major limitations to current, empirical knowledge about alcohol
use and problems within this population
C. Describe the prevalence and etiology of alcohol use within the gay and
lesbian population as it is currently understood
D. Discuss barriers to prevention and treatment of alcohol problems within
this population and ways that those barriers may be addressed

Definitions

"Research tells us that
lesbian, gay, bisexual and transgender people are more likely to smoke, drink,
and use other drugs, than our non-LBGT peers. We're less likely to abstain
and more likely to continue heavy drinking into later life. Does this mean
that we have higher rates of addiction and other serious substance abuse problems?
Who knows? As an oppressed and often invisible population, we don't even know
how many of us there really are, much less what percentage of us fall into
any category. Even these labels -"lesbian," "gay," "bisexual,"
"transgender"-are arbitrary and by no means acceptable to all of
those we describe this way. But there is one fact we know for sure-and it
doesn't require one cent of further research to confirm: there is an appalling
and unacceptable absence of substance abuse services and competen-cies throughout
the continuum of care-from research funding, to public education and other
social marketing, to targeted prevention, to effective treatment-to meet the
needs of America's LGBT women and men. It's up to us to change that."
(NALGAP Board Member, June 2000, as cited on NCADI web page, http://www.health.org/features/lgbt/substance.htmll)

Sexual orientation and gender identity
are complicated constructs that encompass multiple dimensions of an individual's
experience. These dimensions include sexual attraction, behavior and fantasies,
as well as emotional, social and lifestyle preferences and self-identification.
Individuals whose present behavior or appearance is labeled by others as lesbian,
gay, bisexual or transgendered may or may not agree with the assigned designation.
Tremendous variability exists in the histories, behaviors, preferences, and
self-identities of the men and women (including adolescents) to whom these
labels are attached. There exists as much diversity among LGBT individuals
in cultural background, ethnic or racial identity, age, income, education,
and residence as exists within the general population.

With these qualifications in mind, it is generally accepted that:

"Lesbian"
or "gay" refers to a woman or a man whose primary sexual and emotional
attachments are to persons of the same gender.

"Bisexual"
refers to individuals who have sexual or emotional attachments to both men
and women, although typically they are not simultaneously involved with
both.

"Transgender"
is a more encompassing term that includes people who do not fit societal
expectations for sex (male/female) or gender (masculine/feminine) role.
This might include people who are cross-dressers or drag performers, or
those who live full time as members of the opposite sex. Transgendered individuals
may identify as heterosexual, lesbian, gay, or bisexual, because gender
identity and sexual orientation are separate, distinct constructs (Hughes
& Eliason, 2002).

Research limitations

Research focused on substance abuse
within the LGBT population has been severely limited in both quantity and
comparability across studies. Stigmatization of non-heterosexual identity
and behavior, resulting from societal homophobia and heterosexism, provokes
reluctance on the part of funding agents and researchers to study sexual orientation,
out of fear of the impact it will have on professional and political careers.
That same fear of stigmatization and rejection leads many LGBT individuals
to avoid participation in the research that is conducted. Due to a lack of
standard definition of sexual orientation and of efforts to develop reliable
estimates or random samples, the reported numbers of LGBT persons within the
general population are confounded. Consequently, representation is uneven
and reported research findings probably do not fully reflect the experience
of most LGBT individuals.

Those individuals who are willing
to participate in research are probably very different from those unwilling
to identify openly as LGBT. Most research participants have been drawn from
convenience samples of individuals who are members of gay identified groups,
attendees at gay events, or patrons of gay bars. As a result, most samples
have included a disproportionate number of white, well-educated, middle class
lesbians and gay men who are open about their identity and perhaps more likely
to be heavy drinkers (among bar samples). Little is yet known about other
racial/ethnic groups, those of lower educational or socioeconomic backgrounds,
adolescents. and older adults, persons who are "closeted" or identify
as bisexual or transgendered, or those who do not frequent bars or clubs.

Table
1
Early Research: Use and Abuse of Alcohol Among Gay and Lesbian Individuals

Table 1 illustrates
studies conducted during the 1970s and early 1980s that reported rates of
alcohol use and abuse among lesbian and gay persons up to three and a half
times higher than rates among heterosexuals (Saghir & Robins, 1973; Fifield,
Latham, & Phillips, 1977; Lohrenz, Connelly, Coyne, & Spare, 1978).
However, these studies were plagued by various methodological limitations,
raising serious questions about the validity of reported findings.

More recent investigations (see
Table 2), employing more rigorous research methods, have identified substantially
lower rates of heavy drinking among lesbian and gay respondents (Bloomfield,
1993; Bradford & Ryan, 1988; Crosby, Stall, Paul, & Barrett, 1998;
Hughes, Haas, Razzano, Cassidy, & Matthews, 2000; McKirnan & Peterson,
1989a; Skinner, 1994; Stall & Wiley, 1988). These rates reflect patterns
of use and related problems that are more similar to, yet still somewhat higher,
than those of heterosexual men and women. Separate analyses for bisexual and
transgendered individuals were not conducted in any of the cited studies.

Based on the available research,
several conclusions can be drawn. Fewer lesbians than heterosexual women abstain
from alcohol. However, at comparable levels of drinking, lesbians report more
alcohol-related problems than do heterosexual women. Lesbian drinking does
not decline with age as it does among heterosexuals, but use among lesbians
appears to be declining as changes in drinking norms have occurred in some
gay and lesbian communities. Thus, the detected changes in drinking behavior
are more reflective of cohort shifts than of developmental phenomena.

Gay men are less likely to abstain
or to drink heavily than are heterosexual men, yet gay men also report more
alcohol-related problems than heterosexual men at lower levels of use. Finally,
use norms among gay men appear to be declining, like the pattern seen among
lesbians.

Numerous explanations have been
suggested to account for the differences in patterns of alcohol use and related
problems experienced by heterosexuals and LGBT persons. Conflicts related
to LGBT identity and internalized homophobia, stressors inherent in the LGBT
lifestyle (heterosexism), incongruities in gender roles and expectancies,
and the centrality of the gay bar as a source of socialization and support
are variables most frequently cited. Research has not confirmed any single
etiological explanation, but gay/lesbian individuals identify societal factors,
including heterosexism and discrimination, as having the greatest impact.

Other demographic, psychosocial, and interpersonal variables have been identified
through general population research as risk or protective factors for substance
abuse problems. These, in conjunction with certain LGBT "lifestyle"
variables, provide the best available information in projecting risk and protective
factors for LGBT substance abuse problems. It must be noted, however, that
the predictive value of these factors for LGBT people has not yet been adequately
evaluated and further research is needed in this area. Following is a brief
discussion of several of these risk/protective factors.

First, it is important to operationalize
the terms "risk factors" and "protective factors."

Risk factors are
defined as:
(1) the variables positively associated with alcohol problems (empirically
observed or hypothesized), such that the variable and the substance
abuse increase or decrease together
(2) variables suggested by previous research or theory to have etiological
significance in the development of alcohol and other substance abuse
or dependence

Protective factors
are defined as:
variables negatively associated with alcohol problems (empirically
observed or hypothesized), such that the variable and substance abuse
increase and decrease inversely to each other
variables suggested by previous research or theory have significance
in the prevention of alcohol and other substance abuse or dependence

Lifestyle variable: homophobia
and heterosexism

The expression of homophobia and
heterosexism is a pervasive force in the lives of many LGBT individuals, ranging
from personal rejection by family and friends, to the absence of institutional
recognition given to committed LGBT partnerships, to victimization by hate
crimes and overt acts of discrimination in housing and employment. The majority
of Americans continue to view homosexuality as "morally wrong" (Dean,
Meyer, Robinson, Sell, et al., 2000) although a growing number believe LGBT
persons should receive equal treatment in housing, employment and other civil
rights. The term "homophobia," originally coined by Weinberg (1972),
was an all-encompassing term, referring to psychological, social, and political
oppression and marginalization (Saulnier, personal communication, February,
2001). The term has since become refined in its usage (Herek, 1992). Homophobia
is now used to refer to psychological distress, as is the case with other
phobias. Heterosexism is the preferred term for referring to social and political
constraints. It is used similarly to other "ism" terms, such as
sexism, racism, ageism, or classism (Appleby & Anastas, 1998).

Lifestyle variable: gay
bar

The gay bar is frequently
identified as a primary source of social contact and, therefore, a major
determinant of heavy drinking among gay men and lesbians (Hughes &
Wilsnack, 1994; McKirnan & Peterson, 1989a; Saghir & Robins,
1973). Historically, the gay bar has functioned as a social center,
and as a refuge from the discrimination and homonegativity present in
mainstream society. While the role and function of the gay bar have
changed over time, both within LGBT communities and among individuals,
it remains central to the social life of many LGBT persons, particularly
young adults. Because access to LGBT services and other social activities
tends to be greater in urban areas, there may be a heavier reliance
upon gay bars in non-urban locales

Lifestyle variable:
coming out and identity formation
The process by which LGBT individuals self-identify and, subsequently,
disclose to others their sexual preference or gender identity is referred
to as "coming out." Growing up in a society that denigrates
LGBT identity, individuals have few role models or safe havens to which
they can turn for understanding of their feelings and experiences. Negotiating
the internal process of selfdefinition, and the social process of disclosure
or remaining "closeted" can engender immense stress, conflict
and confusion.

Demographic variable:
ageGeneral population studies indicate that the quantity and frequency
of alcohol use declines with age. Among LGBT individuals, the decline
is less dramatic. One study found that daily drinking among lesbians
increased with age (Bradford & Ryan, 1988).

Demographic variable: gender
General population studies indicate that being female is somewhat protective
against alcohol abuse. Among LGBT individuals, there are smaller differences
between men and women in the quantities of alcohol consumed and the consequent
problems experienced.

Demographic variable: race/ethnicity
By and large, general population studies indicate that white men and women
are more likely to use alcohol than are their nonwhite counterparts. Very
limited data suggests that LGBT persons of color are more like other LGBT
persons than they are like their racial/ethnic heterosexual counterparts.

Demographic variable: social
roles/responsibilities
General population studies associate unemployment and unwanted employment
status with increased drinking; the combination of employment, marriage, and
parenting is believed to be protective against drinking problems. Many LGBT
persons are underemployed, they cannot legally marry, and relatively few have
children. Stressors associated with the lack of access to, or support for,
these roles diminish the protective capacity among LGBT individuals, and may
increase risk. The future effect of new civil union legislation is uncertain.
Despite an apparent increase in the frequency of parenting, especially among
lesbians (often referred to as the "lesbian baby boom"), fewer LGBT
people have children as compared to the general population (Parks, 1998; Patterson,
1992; Gartrell, Banks, Hamilton, Reed, Bishop, & Rodas, 1999).

Psychosocial factors: depression/stress
General population studies document the relationship between negative life
events and depression, and between depression and drinking, particularly among
women. LGBT studies indicate no differences in psychological adjustment of
gay men and lesbians from heterosexuals, although LGBT persons may be at greater
risk for depression and stress. However, evidence is mixed regarding the use
of alcohol in response to stress or depression among LGBT individuals. The
high rate at which LGBT persons use mental health services may provide a buffering
or protective effect on the relationship between stress, depression and alcohol
abuse.

Interpersonal factors: childhood
sexual abuse (CSA)
General population studies suggest a relationship between CSA and alcoholism
among both men and women. Limited research suggests that the rate of CSA among
lesbians and gay men may be higher than that among heterosexuals, indicating
a potentially high risk factor for substance abuse. Findings regarding the
association between CSA and sexual orientation are inconsistent, with some
researchers finding an association (Cameron & Cameron, 1995; Saewyc, Bearinger,
Blum, & Resnick, 1999) and others not finding a significant relationship
(Bernhard, 2000; Saulnier & Miller, unpublished).

Interpersonal factors: intimate
partner/domestic violence
A significant proportion of persons involved either as victims or perpetrators
in intimate partner/domestic violence report use of alcohol or other drugs
during or prior to the incidents of battering. The few studies that included
LGBT participants indicate that gay men and lesbians are equally likely as
heterosexuals to experience violence in their intimate partner relationships.
The isolation and stigma associated with intimate partner/domestic violence
is compounded for LGBT persons, thus heightening the risk potential of this
factor for substance abuse.

Interpersonal factors: peer
and partner drinking
Women have a tendency to engage in drinking patterns that parallel those of
their significant others, and this serves as a significant risk factor for
problem drinking among heterosexual women. Because fewer lesbians abstain
from alcohol, they are more likely to couple with a drinking partner, potentially
increasing this risk factor among lesbians. Evidence also suggests that drinking
practices of both partners and peers influence the drinking patterns of gay
men.

The above is not intended as an
exhaustive listing of risk and protective factors that may affect LGBT alcohol
use and abuse. It is a sampling of those factors that have received at least
some limited research attention. Other important areas of protection and risk
related to LGBT community characteristics and societal awareness have been
suggested and require further research investigation to evaluate. These include
the effects of community changes in drinking norms (Hall, 1993) and increased
target marketing (Drabble, 2000).

Prevention and
Treatment: Barriers and Suggested Strategies

Stigma, intolerance, and
overt discrimination are the most substantial barriers to both prevention
and treatment of alcohol use among LGBT persons. As a result of these
factors, LGBT youth and adults lack access to healthy role models
who can help foster positive identity formation and self-esteem. Availability
and access to supportive and affirming social service resources and
substance free social/recreational outlets is also limited. This contributes
to greater marginalization and feelings of isolation among LGBT individuals,
and increases their consequent vulnerability to substance use.

Stigma,
intolerance, and overt discrimination are the most substantial barriers
to prevention and treatment of alcohol use disorders among LGBT persons.

Social work (and other helping) professionals are inadequately trained in the
special needs and concerns of LGBT individuals and may personally harbor the
same homophobic and prejudicial attitudes expressed by a majority of the general
population (Schwanberg, 1993; Stevens, 1992). Past experience with service providers
who attempted to address their sexual orientation, rather than focus on the
presenting problem, has caused many LGBT persons to be distrustful and guarded
about seeking help (Bradford, Ryan, & Rothblum, 1994; Saulnier, 1999; Saulnier
& Wheeler, 2000). Lack of LGBT specific or culturally sensitive screening
and assessment instruments, use of treatment modalities that involve group disclosure,
and lack of adequate insurance coverage are additional barriers to LGBT individuals
receiving care. If group treatment interventions involve mixed populations (rather
than LGBT-specific composition), social workers need to guard against marginalization
or scapegoating of LGBT participants (Saulnier, personal communication, February,
2001) and against the emergence of heterosexism.

Education, visibility, inclusion, and further research are perhaps the strongest
antidotes to each of these barriers. Prevention efforts must focus heavily on
youth, including information about substance abuse and sexual orientation in
outreach and educational activities in the schools and with community caregivers.
Professional training for professionals and the creation of environments in
service agencies that affirm LGBT staff and clients will enhance visibility
of positive rolemodels and improve accessibility of services. LGBT individuals
and their family members (whether biological or defined as family by LGBT individuals)
should be appropriately included in prevention programming and treatment activities.
"Extended family" may not be related biologically or as family of
origin; friends, ex-partners and others from the LGBT community may be significant
in an individual's recovery. Appropriate inclusion varies by situation and circumstances.
For example, given the seriousness of preliminary evidence about the danger
in LGBT youth coming out to their families (D'Augelli, Hershberger, & Pilkington,
1998), social workers should carefully avoid routinely encouraging adolescents
to come out to their families and should help them to explore safe strategies.
Existing networks of LGBT groups and organizations should likewise be consulted
and engaged as resources in prevention, outreach and aftercare services. Finally,
further research with a broader representation of LGBT individuals needs to
be conducted. All of these efforts will help to improve services and outcomes
in the prevention and treatment of alcohol abuse among LGBT individuals.

Classroom Activities

See the article: Neisen, J.
(1997). An inpatient psychoeducational group model for gay men and lesbians
with alcohol and drug abuse problems. Journal of Chemical Dependency Treatment,
7, 37-52.
Consider the agency in which you currently work, or have worked in the past.
Would an LGBT individual find the setting, program, and staff to be supportive,
knowledgeable and affirming of LGBT issues? What antigay/heterosexist elements
would you need to address? What gay affirming programming and service elements
exist? Draft a report to your supervisor that describes and discusses these
points.

Review at least three screening/assessment/diagnosis
instruments for their applicability to LGBT individuals. What additional
information should be included? How can you respond to the factors that
enhance motivation in this population? Devise a 10-15 item instrument and
a plan for testing it with this population (sampling and reliability/validity
issues likely to arise in validating your instrument).

Visit a minimum of four of
the websites listed in this module. Report to your classmates about what
you found at each site.

Discussion Questions

What organizations and services
are available to LGBT clients served by your agency? Is information about
those organizations or services posted in public locations throughout your
agency? How can you act to insure that LGBT individuals within your agency
or practice receive the message that it is safe to disclose that identity?
Is it safe? Is sexual orientation written in the client's record? Who makes
that decision?

What are the pros and cons
associated with intervention groups that are specifically for LGBT members
versus those that mix populations? What issues and concerns are important
for the LGBT social worker to address with each of these types of groups?
What issues and concerns are important for the non-LBGT social worker?

References

Achilles, N. (1967). The development
of the homosexual bar as an institution. In J. H. Gagnon, & W. Simon (Eds.),
Sexual Deviance, (pp. 228-244). New York: Harper and Row.

Israelstam, S., & Lambert, S. (1989). Homosexuals who indulge in excessive
use of alcohol and drugs: psychosocial factors to be taken into account by
community and intervention workers. Journal of Alcohol and Drug Education,
34, 54-69.